Prevalence, causes and contexts of childhood overweight and obesity in the Pacific region: a scoping review

Background Non-communicable diseases (NCDs) are a major threat to health and development and account for 75% of deaths in the Pacific Islands Countries and Territories (PICTs). Childhood obesity has been identified as a main risk factor for NCDs later in life. This review compiled overweight and obesity (OWOB) prevalence (anthropometric data) for children aged six to 12 years old living in the Pacific region and identified possible related causes. Methods We conducted a systematic search using PubMed, Google Scholar and ScienceDirect for articles published between January 1980 and August 2022. We also searched for technical reports from Ministries of Health. Guided by the eligibility criteria, two authors independently read the selected articles and reports to extract and summarise relevant information related to overweight and obesity. Results We selected 25 articles, two worldwide analyses of population-based studies and four national reports. Information revealed that childhood OWOB prevalence reached 55% in some PICTs. This review also indicated that age, gender and ethnicity were linked to children’s weight status, while dietary practices, sleep time and level of physical activity played a role in OWOB development, as well as the living environment (socio-economic status and food availability), parenting practices and education level. Conclusion This review highlighted that anthropometric data are limited and that comparisons are difficult due to the paucity of surveys and non-standardized methodology. Main causes of overweight and obesity are attributed to individual characteristics of children and behavioural patterns, children’s socio-economic environment, parenting practices and educational level. Reinforcement of surveillance with standardised tools and metrics adapted to the Pacific region is crucial and further research is warranted to better understand root causes of childhood OWOB in the Pacific islands. More robust and standardized anthropometric data would enable improvements in national strategies, multisectoral responses and innovative interventions to prevent and control NCDs.


Introduction
The burden of Non-Communicable Diseases (NCDs) is growing swiftly and is a major threat to health, social and economic development, particularly in low and middle-income countries where resources are often limited 1 .NCDs can cause severe disabilities impacting individuals' quality of life and leading to premature deaths.They also present a heavy burden to health care systems and challenge the achievement of the Sustainable Development Goals 1 .NCDs are generally associated with adulthood, but can develop during childhood and adolescence 2 .
Childhood obesity in particular, is reaching alarming proportions in many countries and is a strong predictor of adult obesity, which ultimately leads to NCDs such as type two diabetes and cardiovascular diseases 3 .The World Health Organization (WHO), estimates that 332 million children aged 5-19 years live with overweight or obesity worldwide in 2016 4 .According to WHO, overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health.Body mass index (BMI) and specific growth charts are commonly used to determine childhood weight status.Worldwide comparison of anthropometric data showed that the highest mean body mass index (BMI) in children aged five-nine and 10-19 years old was observed in the Pacific region, with an obesity prevalence of over 30% in some countries 5 .
The Pacific region includes 22 Pacific Island Countries and Territories (PICTs) generally grouped into three geographical and cultural zones: Micronesia, includes the Commonwealth of the Northern Mariana Islands, Palau, the Federated States of Micronesia, Kiribati, the Republic of Marshall Islands, Guam and Nauru; Melanesia covers the region encompassing Papua New Guinea, the Solomon Islands, Vanuatu, Fiji, and New Caledonia; and Polynesia which includes Tuvalu, Tokelau, Wallis and Futuna, Tonga, Samoa, American Samoa, Niue, the Cook Islands, French Polynesia and Pitcairn (see Figure 1).Many are sovereign states, but some are associated states or territories of other nations 1 6 .Due to immigration flows, the inhabitants of PICTs, referred to hereafter as "Pacific islanders", have formed important diasporic communities in developed Pacific rim countries, such as New Zealand, Australia and USA, especially the state of Hawai'i 7 .
Over the past few decades, overweight, obesity and related noncommunicable diseases (NCDs) have progressively increased in every age group and have become the major cause of premature death and disability in the Pacific.Overweight affect more than 50% of the population in many Pacific countries 8 and more than one-third of both sexes are obese.
Furthermore, the prevalence of obesity is higher in Pacific islanders compared to other ethnic groups living in the Pacific region 8 .Within the Pacific islanders, anthropometric data showed that Polynesians have higher BMI than Melanesians, in both adults and adolescents 9,10 .Furthermore, the results of the 2002 National Children's Nutrition survey conducted in New Zealand children aged five to 14 years old revealed that extreme obesity affects one in 10 Pacific islander children, compared to one in 100 children from New Zealand with European origin 11 .
With more than 5,500,000 inhabitants under 19 years old in the Pacific region 12 , the issue of overweight and obesity during childhood requires urgent public health attention.Regional organizations are supporting PICTs in implementing standardized surveys to monitor the health of children in the Pacific region.These include anthropometric data for adolescents (13-18 years old) through the WHO Global School Based Health Survey, information about the BMI of children under five years old and adolescents/adults 15 years and over from Demographic Health Surveys supported by the Asian Development Bank and the Pacific Community, overweight/obesity and diabetes in the 15-17 year age group through the WHO supported STEPwise approach to surveillance surveys (STEPS) and BMI data in children aged 13-17 years in the Health Behaviour and Lifestyle of Pacific Youth Surveys (HBLPY).These surveys all capture data for the five year olds and under and 13-17 years age categories.However, there is lack of reported data for children of primary school age (six to 12 years old).Collecting anthropometric data for this age group is therefore a priority to improve the prevention of childhood obesity 13 .
To address childhood overweight and obesity, it is important to monitor children's BMI to assess trends and drive interventions and policies, but it is also critical to identify the root causes.Unhealthy eating habits and an insufficient level of physical activity are often mentioned in relation to childhood obesity 14 , as well as low sleep duration and high screen time use 15 .However, the behaviour of children is not enough to explain the development of obesity.Childhood obesity is also linked to social, economic, and environmental determinants including family behaviours, education, food availability, transport, accessibility to sports facilities, food and beverages marketing strategies 16,17 .In some US-Affiliated Pacific Islands (USAPI), the Youth Risk Behavior Surveillance System (YRBSS) has been used to monitors six categories of health-related behaviours among adolescents aged 13-18 years old.The Children's Healthy Living Program for remote and underserved minority populations in the Pacific (CHL) has been monitoring the prevalence of overweight and obesity in children aged 2 to 8 years.The latter has also been monitoring the implementation of interventions addressing policy, environment, messaging, training, and those interventions targeting behaviours including sleep time, screen time, physical activity, intake of fruits and vegetables, water and sugar-sweetened beverages 18 .Despite these, to date, there are a limited number of studies evaluating the causes of childhood overweight and obesity of children in PICTs.
Therefore, the aim of this review was to conduct a comprehensive review of all available information regarding overweight and obesity prevalence in PICTs for children aged six to 12 years old and to summarize the prevalence and the known causes of overweight and obesity among this age group.

Methods
We conducted a systematic search of peer-reviewed articles published between January 1980 and August 2022.PubMed, Google Scholar and ScienceDirect databases were searched using the keywords "overweight or obesity," "children," and "Pacific islands".We also conducted a search with specific terms (anthropometry, nutritional status, childhood obesity determinants, childhood obesity root causes, childhood obesity risk factors), individual PICTs names (American Samoa, Cook Islands, Fiji, French Polynesia, Guam, Kiribati, New Caledonia, Niue, Commonwealth of the Northern Mariana Islands, Palau, Papua New Guinea, Pitcairn Islands, Samoa, Solomon Islands, Tokelau, Tonga, Marshall Islands, Federated States of Micronesia, Nauru, Tuvalu, Vanuatu, and Wallis and Futuna) and subregions in the Pacific (Melanesia, Micronesia and Polynesia).A similar search was conducted in French as it is an official language in four PICTs (French Polynesia, Wallis and Futuna, New Caledonia and Vanuatu).Articles were all screened by title and abstract according to the inclusion criteria (see Table 1).Relevant full-text articles were retrieved and included in the review.The search also included technical reports from authoritative sources e.g. the Health Ministry of PICTs.Two authors independently read all the selected articles and reports to extract and summarise relevant anthropometric data (see Table 2).If any uncertainty for inclusion, a discussion was made and resolved with a third author.   oss-sectional (2015)

adolescent girls aged 9-13 years old
There were correlations between cognitive restraint, uncontrolled eating, emotional eating and BMI.
Due to the paucity of surveys that explored childhood obesity and overweight causes in PICTs, the search was extended to New Zealand and Hawai'i.Articles were added only where they were including Pacific islanders and exploring determinants of overweight or obesity as results (see Table 3).Due to the diversity and relatively small number of studies on this topic, no attempt was made to evaluate individual study and there were no restrictions on study design.

Results
The search retrieved 786 articles and four national reports as shown in the PRISMA-ScR flow diagram in Figure 2 49 .The PRISMA-ScR checklist for this study is also publicly available 50 .After initial screening, 97 documents met the inclusion criteria.There were 35 articles and four national reports reporting studies conducted in PICTs, 14 articles in Hawai'i and 44 in New Zealand.Of these, 46 were excluded because they were related to the same study and provided no additional information, the sample's age did not meet the criteria (e.g.2-6 years old or 12-18 years old) or the study reported an intervention.

Characteristics of included studies from PICTs
Selected articles included: 22 original studies, reported across 25 articles, two worldwide analyses of population-based studies and four national reports (see Table 2).
Six studies aimed to monitor childhood obesity at a national level: Guam, New Caledonia, Fiji, French Polynesia, Wallis-and-Futuna and American Samoa 23,24,[33][34][35]41 . Thee national studies were conducted in school settings and included all students, or a proportionate-to-population sized cluster samples.But most of the studies accessed the children through communities/households.In some studies, the main objective was to explore other health conditions (anaemia, oral health, acanthosis nigricans, etc.) rather than in measuring overweight/obesity prevalence 23,26,47 .
All included studies reported on measured anthropometric data (no self-report), however, no consistent reference method was used.Across the studies, the prevalence of overweight and obesity was measured using WHO (n=10), Centre for Diseases Control and Prevention (CDC) (n=16), International Obesity Task Force (IOTF) (n=9) or French BMI reference standards (n=3).Due to the number of different child growth references available, studies performed in PICTs often presented anthropometric data using two (or even sometimes four) reference standards to allow for comparison with other studies.The northern jurisdictions (US territories, Commonwealths and freely associate states) used the CDC reference standards only.There were no articles reporting on anthropometric data from Tokelau, Palau, Tuvalu, Niue, Kiribati, Nauru and Pitcairn.
Childhood overweight and obesity prevalence in PICTs reported in the articles Due to the diversity of the results presented in the articles, we chose to focus on reporting on the outcome of excess weight (overweight and obesity both included) hereafter identified as OWOB.Where possible and relevant, overweight and obesity data are presented separately for more precision (see Table 2).
According to the studies included in this review, overall childhood OWOB prevalence in PICTs reached 40% in Micronesia (7-10 years old) and was above 55% in Polynesia (7 -16 years old).For the Melanesian areas, obesity affecting 1.7% of the children in Fiji (5 -14 years old) and up to 25% in New Caledonia (12 years old).Obesity was ranked between 5.1% and 23.6% in Micronesia and was above 40% in Polynesian countries.
Determinants identified can be divided into four main subgroups: children's characteristics, children's behavioural patterns, parenting practises/education level and socio-economic environment (Figure 3).
• Children's characteristics: Ethnicity was associated with BMI, with Polynesians found to have higher BMIs than other Pacific islanders.Indeed, results from pluri-ethnic PICTs show that Polynesian children are particularly at risk of obesity.For instance, in New Caledonia, obesity rates are 22.1% for Melanesians and 25.1% for Polynesian children 23 .In the USAPI study 47,48 , prevalence of obesity varied among Pacific race/ethnic groups, with Polynesians found to have a higher rate of obesity than Micronesians.A similar trend for ethnicity was also observed in surveys conducted in New Zealand and Hawai'i.Native Hawaiian boys aged 8-9 years old were found to be significantly more overweight than their classmates 51 .In New Zealand, extreme obesity was found to affect one in 10 Pacific islander children and one in 20 Māori children, compared to one in 100 New Zealand European 11 .
Studies with pooled anthropometric data indicated that the prevalence of OWOB increases with age.For instance, obesity rates in New Caledonia were 7.8% at six years old, 11.4% at nine years old and 20.5% at 12 years old 23 .In the USAPI, children 6-8 years old were more likely to be obese than children 2-5 years old (16.3% compared to 12.9%) 48 .In American Samoa, the OWOB rate was 41.3% for grade two children, 43.9% for grade three and 50% for grade five 29 .It was also found that sex might influence weight status.In the USAPI, boys aged 2 to 8 years old were more likely to be obese than girls (16.3% vs 11.6%) 48 .In Samoa obesity rates were 17.5% for boys and 4.6% for girls based on WHO z-scores for children 3-7 years old 32 ..The survey conducted by the American Samoa Department of Health found that reliance on vehicles rather than walking to school and social norms that were skewed towards accepting obesity are risk factors to OWOB 34 .This is consistent with results from a study conducted by Brown et al. in Hawai'i where high physical activity levels were significantly related to lower BMI, waist circumference and body fat percentage 55 .In contrast, inactivity was significantly positively correlated with body fat percentage for students grade three (eight years old) 55 .

• Children's behavioural patterns:
• Parenting practices and education level: Parenting practices and caregivers' education level were also associated with children weight status., Novotny et al.
found that children from Northern Mariana Islands who had been breastfed had significantly lower BMIs than those who were not 37 .It was also reported that children with overweight or obesity in Guam were more likely to have educated caregivers (over 12th grade) 45 .However, these findings are inconsistent with the results of studies conducted in Hawai'i, where it was found that the father's level of educational attainment was inversely related with their daughter's adiposity 51 .Similarly, lower maternal education was associated with greater childhood overweight and obesity 53 , and the National Survey of Children's Health indicated that the prevalence of OWOB decreased with greater numbers of years of parental education 52 .

Socio-economic environment:
The environment in which children evolve affects their health status.For instance, the food store environment plays a role in the OWOB rate.In Guam, living close to a small market was associated with a lower BMI while children who lived close to a convenience store had a higher BMI 43 .
Children living in a lower to middle income jurisdiction in USAPI were less likely to be obese than those from higher income jurisdiction 48 .Similarly, in the Marshall Islands, obesity prevalence was higher in children attending private schools 44 .The results for two comparative studies 27,30 showed that children living in the islands (Samoa and Cook Islands) were less obese than Samoan children living in Hawaii or Cook Islander children living in New Zealand.The studies attributed this to the more traditional ways of life practiced in both Samoa and Cook Islands.

Discussion
This scoping review provides an overview of the prevalence and determinants of childhood OWOB in PICTs, specifically among 6-12-year-olds.This review found that the prevalence of overweight and obesity reached 55.6% (CDC BMI reference tool) in some PICTs and childhood obesity ranged from 1.7 to 35.5% across the Pacific region (WHO BMI reference tool).The review highlighted that the most commonly observed factors associated with childhood OWOB are children's individual characteristics and behavioural patterns, parenting practices and education levels, and children's socio-economic environment.
Overweight and obesity prevalence in children living in the pacific region: data availability, tools and methods The prevalence of OWOB in children aged six to 12 years old observed in this review (see Table 2) is higher than what is observed in high-income countries or related states of the region such as New Zealand where obesity prevalence is 9.4% (2-14 years old), 8% in Australia (5-14 years old), 18.4% in the United states (6-11 years old) 70 and 3.9% in France (6-17 years old) 71 .
At the same time, this review revealed an incomplete picture of childhood OWOB across the region related to disparity of anthropometric data available, tools and methods used.Among the literature, anthropometric data availability and mechanisms for reporting of child growth monitoring have often been described as key issues that need to be addressed to drive health policies and monitor interventions in PICTs 13,72,73 .
In the region over the past decade, more studies have been conducted in Polynesian and English-speaking countries compared to Melanesian and French territories (see Table 2).The presence of research units as well as non-governmental organisations have also likely influenced the way and where anthropometric data are collected.Also, limitations in human and financial resources in PICTs do not always allow national health surveys to be undertaken in a periodic manner to collect valid and reliable anthropometric data that can then inform understanding of the trends of OWOB among these PICTs.Hence, the combination of these factors has contributed to the gap in accessibility and availability of anthropometric data related to childhood OWOB in the Pacific region.Furthermore, we only found a few articles published by local governments and national reports, however these were not readily available/ accessible for public use.Collaboration between ministries of health and regional universities should be encouraged to facilitate analysis, publication, and dissemination of results.
Obesity is commonly defined as an excess of fat accumulation that present a risk for health.There are indirect methods available to calculate fat mass such as the dual-energy X-ray absorptiometry (DEXA), bioelectrical impedance analysis (BIA) and densitometry 74 .However, those methods required specific equipment and/or expertise and are thus inadequate for use in national surveys.Anthropometric measures are less accurate for measuring the excess of body fat, but they are more practical and easier to use to monitor childhood obesity.The most common used ones are subcutaneous skinfolds, height, weight, waist and body circumferences to calculate ratios, percentage of body fat or BMI 75 .All the studies analysed in this review used BMI to assess the weight status of children.This is likely because it is relatively cheap to collect the anthropometric data and easy to calculate.However, assessing the BMI of children requires consideration of biological maturation.Therefore, children's BMI is categorised using a variable threshold that considers the child's age and sex.The most commonly used BMI reference tools are the one provided by WHO 76 , CDC 77 and IOTF 78 .Each growth reference tends to have a set of recommended thresholds defined by statistical conventions, e.g. a whole number of standard deviations from the mean or a whole number of centiles.Studies analysed in this review used a combination of all those references to determine BMI and OWOB in children.Thus, any interpretation of children OWOB at a regional level, remain an estimate if based on existing literature.Therefore, future surveys need to be standardised at a regional level to better monitor childhood obesity in the Pacific region.The COSI Protocol developed in Europe by WHO could be a good starting point 79 .There is also a need for multi-country studies (e.g.studies that involve at least 2 PICTs) to allow for comparisons between countries.In addition, WHO has acknowledged the need for culturally specific standards because current BMI-for-age charts are not appropriate for Asian and Pacific island children 80 ; implying that any interpretation needs to be cautious and the necessity for this tool to evolve in the future.

Root causes of overweight and obesity in children living in the Pacific region
This review also highlights some possible root causes of childhood obesity in the Pacific region.For instance, ethnicity plays a major role in the development of obesity, and similar results are found in other countries such as the United States of America where White and Asian American children have significantly lower rates of obesity compared with African American and Hispanic children 81 .The impact of ethnicity on overweight has also been observed in adolescents in the Pacific region 82 .This factor should be considered in future research and studies focused on Oceanians of Non-European, Non-Asian Descent (ONENA), which could be relevant in some PICTs 83 .The prevalence of overweight and obesity has also been found to increase with age, which is consistent with what is observed in other countries such as Australia 84 .The review also highlights that boys are more affected by obesity than girls in the Pacific for children aged six to 12 years old.Similar findings have been published in other regions, e.g. the WHO COSI survey conducted in 36 European countries, where the prevalence of obesity tended to be higher for boys than for girls aged six to nine years old 79 .
Our findings revealed that lifestyle influences OWOB prevalence in children living in the Pacific region.Studies included in the review showed that diet (especially consumption of SSBs/snacks and, absence of breakfast) was associated with children weight status.The eating habits of Pacific Islanders have been profoundly modified with the establishment of commercial exchanges increasing access to processed products, to the detriment of local healthy foods [85][86][87] .Among dietary habits related to weight gain, the link between consumption of sugary drinks and OWOB has been clearly established 88,89 .
Studies implemented in the Pacific region have highlighted the high consumption of SSBs by children and adolescents 45,90,91 .WHO recommends SSB taxation as an efficient tool to reduce consumption 92 .There are SSB taxes in 16 of 21 PICTs 93 but more efforts are required especially to ensure that SSBs are not easily accessible to children.Strong school food policies, effective restrictions on food marketing and school or community based interventions are essential [94][95][96] .
Regarding physical activity, information was limited in the articles retrieved for this review.In 2020, WHO released updated recommendations: "children and adolescents should do at least an average of 60 min per day of moderate-to-vigorous physical activity across the week" 97 .To ensure that children meet those recommendations, governments are strongly encouraged to include physical activity in their national school curriculum.This is currently monitored through the Pacific Monitoring Alliance for NCD Action (MANA) framework.
According to the Pacific MANA, 15 PICTs have included physical activity as a compulsory component of the school curriculum 98 .School interventions that include promotion of daily physical activity also need to be strengthened in the region; like the Healthy Child Promising Future project implemented in Fiji and Wallis-and-Futuna, which assigns 30 minutes of daily physical activity to be included in school time 99 .Furthermore, the country-driven Pacific Ending Childhood Obesity Network (Pacific ECHO), established in 2017, has a strategic priority area focused on the development of a region-wide physical activity campaign and aims to support physical activity interventions for children 73 .
As part of healthy lifestyles, this review found that sleep duration was linked to childhood OWOB.The association between sleep and weight status is well documented in the literature 98 , but there is limited anthropometric data available in the Pacific.WHO has released sleep time guidelines only for children under five years 99 .However, based on anthropometric data collected in USAPI, the CHL program has developed tools for communities and tips for caregivers to increase children's sleep time using CDC recommendations.Breastfeeding appears to be a protective factor regarding OWOB in our review.WHO and UNICEF recommend exclusive breastfeeding for six months to achieve optimal growth, development and health.According to the State of the World's Children 2016 data, 55% of children are exclusively breastfed during the first six month after birth in the Pacific 100 , with disparities between countries (74% in Solomon Islands to 31% in Republic of Marshall Islands); but still higher than what is observed in Pacific islands families living in New Zealand 101 .To maintain good rates of breastfeeding, PICTs should implement measures to regulate the promotion of breast-milk substitutes 102 .
The role of the environment in children's weight status needs to be considered in too.The income level of children's living area is associated with OWOB rates in studies conducted in USAPI.This finding can be extended at regional level by using the World Bank country classifications by income level PICTs with lower income levels were less affected by overweight and obesity.This can be explained by the lack of financial means of households, which encourage family farming activities rather than buying often processed or highly processed food from supermarkets or convenience stores.Affluence leads to the purchase of unhealthy food products and gives access to technologies that promote a sedentary lifestyle.This has been already observed in 103,104.
In our analysis, we draw special attention to important knowledge deficits on the topic of OWOB and its roots causes in children living in the Pacific region.More research is required to better understand socio-cultural determinants of childhood OWOB.Among the 47 articles reviewed, only one qualitative study was listed.Indeed, qualitative analysis is essential to identify risk factors that might be specific to the region and have not been explored elsewhere and/or observed with quantitative surveys.So, it is relevant to set up mixed longitudinal studies such as the Pacific Islands Families Study 105 implemented in New Zealand among children of Pacific Islanders exclusively to study the evolution of the anthropometric characteristics of children during their growth, but also social determinants that could explain overweight and obesity.Our scoping review has some limitations.We made the choice to add grey literature through reports available online.Unfortunately, many PICTs are collecting children OWOB data but they are not being analysed and reported, especially in publicly available reports.Nonetheless, this review provides an overview of the available anthropometric data on OWOB prevalence for children between six to 12 years old and the current root causes identified in the Pacific region.

Conclusion
The results of this review indicate that unhealthy behaviours and lifestyles are prevalent in children and brings new information on the causes of obesity in children in an understudied population.The study illustrates concerning trends particularly with the prevalence of overweight and obesity reaching up to 55% in some PICTs and childhood obesity ranging from 1.7% to 35.5% across the Pacific region.These trends are attributed to the individual characteristics of children and behavioural patterns, parenting practices and educational level, and children's socio-economic environment.Although anthropometric data was limited and comparisons difficult due to the paucity of surveys and the varying range of tools and methods used to monitor childhood OWOB, this review highlights the critical need for more robust anthropometric data and more qualitative studies to explore childhood OWOB root causes.This will provide a more nuanced understanding of the environments and communities children operate in and provides opportunities to interrogate further how their choices are shaped.This will better inform the development of suitable intervention programs that can better address the obesogenic environment and critical periods in the life course to tackle childhood overweight and obesity.

Reviewer Expertise: Nutrition, obesity, hormones
We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Version 1
Reviewer The manuscript of Bertand-Protat et al is a scoping review aiming at presenting a comprehensive review of all available information regarding overweight and obesity prevalence in the Pacific islands countries and territories for children aged between 6 and 12, as well as causes and contexts.The methodology used for the review is well exposed and the data clearly presented.
Although the number of selected articles is rather low, this report is very interesting.Indeed, this population of children in this part of the world is understudied although the prevalence of overweight and obesity is alarmingly high, reaching over 55% in some of the Pacific islands countries and territories.In addition to the prevalence, the authors have complied and then discussed the determinants of overweight and obesity in the different Pacific islands studied, providing an interesting basis for future investigations and interventional studies.The limitations of the various studies, and therefore of the review, have also been discussed by the authors.
Here are some comments aiming to improve the manuscript: The title starts with "causes and contexts of childhood OWOB…" while a great part of the review is on the prevalence of OWOB.It seems more appropriate to start the title with "Prevalence, causes and contexts of childhood.."

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In the plain language summary, the authors write "This scoping review aims to understand the causes of overweight and obesity prevalence for children aged six to 12 years old living in the Pacific region and identified possible related causes."This sentence needs to be rephrased.I would suggest again here to present the work on prevalence and then causes and contexts.

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A definition is given for overweight and obesity ("Overweight and obesity are defined as ○ abnormal or excessive fat accumulation that may impair health.")but the 2 conditions are not distinguished although they have different health consequences.This should be clarified and references of the definition cited.
The review includes articles from 1980 but the rationale of this criteria is not explained.Does it has to do with the "faster access to modern life in the past few decades" mentioned in the plain language summary?○ in the introduction, end of second paragraph, it would be interesting to have the figures of mean BMI in children in the Pacific region.
○ Similarly, at the beginning of the 4 paragraph of introduction , inclusion of figures for BMI would provide more concrete information.

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In the method, it is not mention clearly if PRISMA for Scoping Reviews methodology was used.

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In figure 2 Google scholar use is not mentioned although it is mentioned in the text; please explain if the data were redundant with Pubmed or else?

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In the results section, the tool for assessing BMI is not mentioned so it is difficult to know how comparisons have been made (eg if the data come from different tools such as CDC or French BMI references standards).

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Figures would be appreciated rather than comparisons such as " Native Hawaiian boys aged 8-9 years old were found to be significantly more overweight than their classmates"

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Please indicate age of children in grade 2 or 3 or 5 in the sentence "In American Samoa, the OWOB rate was 41.3% for grade two children, 43.9% for grade three and 50% for grade five 29.It was also found that sex might influence weight status."

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In the discussion, replace "systematic review" by "scoping review" ○ More emphasis could be done on the fact that in some countries BMI is positively correlated with higher parents' income (USAPI) or education (Guam) and attending private school (Marshall islands) while in other islands the correlation is negative as often reported in most countries of the world.

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More emphasis could be made also on the limitations of BMI measure.For example it is known that muscular person will have a high BMI, therefore overestimating their fat mass.This can be corrected with HDL cholesterol and waist circumference measures.Similarly person with low stature would have a low BMI when their fat mass might be high.

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Are the rationale for, and objectives of, the Systematic Review clearly stated?Yes Are sufficient details of the methods and analysis provided to allow replication by others?

Is the statistical analysis and its interpretation appropriate? Not applicable
Are the conclusions drawn adequately supported by the results presented in the review?Yes Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Nutrition, obesity, hormones
We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.defined as abnormal or excessive fat accumulation that may impair health.")but the 2 conditions are not distinguished although they have different health consequences.This should be clarified and references of the definition cited.
Authors: this is WHO definition.This information has been added to the manuscript.Please see Page 5 line 24 4. The review includes articles from 1980 but the rationale of this criteria is not explained.Does it has to do with the "faster access to modern life in the past few decades" mentioned in the plain language summary?Authors: The rationale is the availability of articles related to the topic of children OWOB in the Pacific region on databases.9.In the results section, the tool for assessing BMI is not mentioned so it is difficult to know how comparisons have been made (eg if the data come from different tools such as CDC or French BMI references standards).Authors: It is not possible to make clear comparison between countries or subregions due to this lake of standardization in tools, methodology, age group, etc. as explained on lines 160-170.However, we've decided to present the most relevant data.

in the introduction
10. Figures would be appreciated rather than comparisons such as " Native Hawaiian boys aged 8-9 years old were found to be significantly more overweight than their classmates " Authors: Thanks for this suggestion but after discussion with co-authors we've decided that there is enough tables and figures in the article.

11.
Please indicate age of children in grade 2 or 3 or 5 in the sentence "In American Samoa, the OWOB rate was 41.3% for grade two children, 43.9% for grade three and 50% for grade five.It was also found that sex might influence weight status."Authors: This information is not provided in the article where data has been extracted.
13.More emphasis could be done on the fact that in some countries BMI is positively correlated with higher parents' income (USAPI) or education (Guam) and attending private school (Marshall islands) while in other islands the correlation is negative as often reported in most countries of the world.Authors: Due to different methodologies used we've decided to not provide more details/explanation on this point.

Introduction:
The introduction contains a lot of interesting and valuable information; however, this section could be better organized.More justification is needed to explain this target age group.Also, a more robust epidemiological background on overweight/obesity in the Pacific would be useful.There are some data from Pacific Islanders living in New Zealand, but no data from the Pacific islands.It is recommended that overweight/obesity data from adults and adolescents be provided to provide context for this issue in the region.
This section also states that collecting anthropometric data from Pacific youth is a priority, although there are limited data available, therefore it makes sense that summarizing available data is also an objective of this review.

Results:
In the first paragraph on page 12, please revise the verbiage to state "northern jurisdictions", and "US territories, commonwealths, and freely associate states".

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In paragraph 3 on page 12, please specify age groups for all OWOB prevalence data listed, as these vary slightly in each jurisdiction.

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The results section summarizes OWOB in the Pacific, so this should be a second objective of this review.

Discussion:
This section begins with a summary of OWOB prevalence data based on this review, so again, this should be considered as an objective.

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In paragraph 1 of this section, it is stated that "high prevalence of OWOB in the region was mainly explained by…".Please consider rewording considering that there is no research that can fully understand this complex issue.Perhaps state that "most commonly observed factors associated with childhood OWOB are…".

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Another limitation to lack of childhood OWOB data in the Pacific is the actual reporting of collected data.Many jurisdictions are collecting these data, but they are not being analyzed and reported, especially in publicly available reports.Consider adding this as a limitation.
○ Are the rationale for, and objectives of, the Systematic Review clearly stated?Partly

Are sufficient details of the methods and analysis provided to allow replication by others? Yes
Is the statistical analysis and its interpretation appropriate?Not applicable

Are the conclusions drawn adequately supported by the results presented in the review? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: non-communicable disease epidemiology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Figure 1 .
Figure 1.Present Pacific region including Micronesia, Polynesia and Melanesia.Source: Prepared by the Publishing Team, Pacific Community (SPC), 2022.

1 .
The study was conducted in at least one of the 22 Pacific Islands Countries and Territories (PICTs) and/or New Zealand or Hawai'i 2. Children aged six to 12 years old were included in the study 3. Overweight or obesity was a primary outcome variable and/or at least one determinant or correlate of overweight or obesity was identified 4. Articles from New Zealand and Hawai'i included Pacific islanders and explored determinants or correlates of overweight or obesity.

Figure 3 .
Figure 3. Main causes of childhood overweight and obesity identified in PICTs.Note: References to studies are indicated in brackets.
Awareness campaigns and interventions related to sleep duration should be widely organized in the region.High intakes of calories, lack of physical activity and hours of sleep are leading to increased weight in children population.Future research needs to focus on social cultural factors that influence children's lifestyle.The Pacific Obesity Prevention in Communities (OPIC) project paved the way by exploring social structures, values, beliefs, perceptions, attitudes and expectations which have a significant influence on Fijian and Tongan adolescents' individual behaviours related to eating, activity and body image 100 .
Report 21 July 2023 https://doi.org/10.21956/openreseurope.16606.r33245© 2023 Moisan M et al.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Marie Pierre Moisan Nutrition et Neurobiologie Intégrée, UMR 1286, University of Bordeaux, Bordeaux, France Rachel Ginieis Nutrition and Neurobiologie Intégrée (Nutrineuro), UMR 1286, NutriPsy team, University of Bordeaux, Talence, Nouvelle-Aquitaine, France

Table 3 . Summary of obesity determinants identified in relevant articles for New Zealand and Hawai'i (n=20). Author (year) Study design (study year) Population Obesity determinants identified Hawai'i 1 Brown et al. (2011) 51
Ethnic disparity in adiposity occurs after the age of 6 years and is confined to males in this study.For older girls, their father's educational attainment was inversely related to adiposity.

, end of second paragraph, it would be interesting to have the figures of mean BMI in children in the Pacific region
Authors: we can't calculate children mean BMI for the whole region because the BMI references used are different (WHO, IOTF, CDC, French references).

at the beginning of the 4 paragraph of introduction, inclusion of figures for BMI would provide more concrete information
Authors: same comment as above.Data are not comparable so we can't provide figures.

In the method, it is not mentioned clearly if PRISMA for Scoping Reviews methodology was used
.Authors: yes, Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist was used.This information is provided on page 26, lines129-130. 8.

In figure 2 Google scholar use is not mentioned although it is mentioned in the text; please explain if the data were redundant with Pubmed or else?
Authors: No relevant articles were found in google scholar, apart from those available on Pubmed.